Dr Tim Davis

A review of Cooled Radiofrequency applications for spine and joint disorders.

Background: A viable disc tissue allograft has been developed to supplement tissue loss associated with degenerative lumbar disc disease and the development of chronic discogenic lower back pain.

Objectives: Viable disc allograft was injected into painful degenerated discs to evaluate safety and determine whether it can improve pain and function.

Study Design: Patients received an active treatment of allograft or saline, or continued with nonsurgical management (NSM). Prior to… Show more

Background: A viable disc tissue allograft has been developed to supplement tissue loss associated with degenerative lumbar disc disease and the development of chronic discogenic lower back pain.

Objectives: Viable disc allograft was injected into painful degenerated discs to evaluate safety and determine whether it can improve pain and function.

Study Design: Patients received an active treatment of allograft or saline, or continued with nonsurgical management (NSM). Prior to entering the study, patients had back pain for a minimum of 6 months before treatment that was recalcitrant to nonoperative treatment modalities. Standardized outcome measures were used to evaluate the patient’s condition before and after treatment. Primary endpoints included improvement in Oswestry Disability Index (ODI) and Visual Analog Scale of Pain Intensity (VASPI). Conventional radiographs and magnetic resonance imaging scans were used to assess disc space height and spinal alignment, and to determine the degree of disc degeneration. Patients were followed for one year after enrollment. The NSM group could cross over to the allograft group after 3 months.

Conclusions: This large, prospective blinded RCT demonstrated safety and efficacy results indicating that viable disc tissue allograft may be a beneficial nonsurgical treatment for patients who have chronically painful lumbar degenerative discs. Further studies would be optimal to confirm efficacy Show less

Degenerative disc disease is a ubiquitously common process that occurs with normal aging but can give rise to back pain that can range from mild to severe. The pain and disability caused by DDD account for a very large number of doctor visits and are the most common causes of disability worldwide. The treatment for DDD has largely been supportive but new biomaterials including fibrin adhesives, platelet-rich plasma, bone morphogenic protein, transforming growth factor, alpha-2-macroglobulin… Show more

Degenerative disc disease is a ubiquitously common process that occurs with normal aging but can give rise to back pain that can range from mild to severe. The pain and disability caused by DDD account for a very large number of doctor visits and are the most common causes of disability worldwide. The treatment for DDD has largely been supportive but new biomaterials including fibrin adhesives, platelet-rich plasma, bone morphogenic protein, transforming growth factor, alpha-2-macroglobulin, and autologous and allogeneic mesenchymal stem cells have been used with varying degrees of success. Some of the recent biologic injectables have shown significant promise in relieving pain and restoring function in patients with painful DDD, and there have also been some signs of anatomic regeneration on cross-sectional imaging evaluation as well. It appears that some of the existing biomaterials will be safe and will be very effective in treating patients with painful DDD. Show less

Objective: The primary objective of this observational, prospective, multicenter study was to evaluate the long-term outcomes, including pain, function, and perceived effect of treatment, in subjects undergoing cooled radiofrequency ablation (CRFA) who have pain due to osteoarthritis (OA) of the knee.

Methods: This analysis included a subset of subjects previously enrolled in a prospective, multicenter randomized study comparing the safety and effectiveness of CRFA and intra-articular… Show more

Objective: The primary objective of this observational, prospective, multicenter study was to evaluate the long-term outcomes, including pain, function, and perceived effect of treatment, in subjects undergoing cooled radiofrequency ablation (CRFA) who have pain due to osteoarthritis (OA) of the knee.

Methods: This analysis included a subset of subjects previously enrolled in a prospective, multicenter randomized study comparing the safety and effectiveness of CRFA and intra-articular steroid injection in patients with knee OA through 12 months who were contacted to participate in this extension study. Subjects were enrolled if they agreed to participate in up to 2 additional follow-ups, at 18 and 24 months.

Results: Eighty-three subjects from the 5 participating sites underwent CRFA during the original study and were contacted for this extension study. Of the 33 subjects enrolled, 25 were evaluated at 18 months after CRFA treatment, and their mean numeric rating scale (NRS) score was 3.1 ± 2.7, with 12 subjects reporting ≥50% pain relief compared to baseline. At 24 months, 18 subjects reported a mean NRS score of 3.6 ± 2.8, with 11 demonstrating ≥50% pain relief. Functional improvement as measured by the Oxford Knee Score continued to be present, with an overall mean change from baseline of 26.0 ± 9.6 points at 18 months and 29.9 ± 10.4 points at 24 months.

Conclusion: In this subset of subjects from a randomized controlled trial, CRFA provided sustained pain relief, improved function, and perceived positive effect through 24 months for subjects with OA knee pain with no safety concerns identified. Show less

Introduction The Neuromodulation Appropriateness Consensus Committee (NACC) is dedicated to improving the safety and efficacy of neuromodulation and thus improving the lives of patients undergoing neuromodulation therapies. With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion (DRG) stimulation has significantly improved the treatment of complex regional pain syndrome (CRPS), among other conditions. Through funding and… Show more

Introduction The Neuromodulation Appropriateness Consensus Committee (NACC) is dedicated to improving the safety and efficacy of neuromodulation and thus improving the lives of patients undergoing neuromodulation therapies. With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion (DRG) stimulation has significantly improved the treatment of complex regional pain syndrome (CRPS), among other conditions. Through funding and organizational leadership by the International Neuromodulation Society (INS), the NACC reconvened to develop the best practices consensus document for the selection, implantation and use of DRG stimulation for the treatment of chronic pain syndromes. Methods The NACC performed a comprehensive literature search of articles about DRG published from 1995 through June, 2017. A total of 2538 article abstracts were then reviewed, and selected articles graded for strength of evidence based on scoring criteria established by the US Preventive Services Task Force. Graded evidence was considered along with clinical experience to create the best practices consensus and recommendations. Results The NACC achieved consensus based on peer‐reviewed literature and experience to create consensus points to improve patient selection, guide surgical methods, improve post‐operative care, and make recommendations for management of patients treated with DRG stimulation. Conclusion The NACC recommendations are intended to improve patient care in the use of this evolving therapy for chronic pain. Clinicians who choose to follow these recommendations may improve outcomes. Show less

Introduction Dorsal root ganglion stimulation (DRGS) is a powerful tool in the treatment of chronic, neuropathic pain. The premise of DRGS is similar to that of conventional spinal cord stimulation (cSCS), however, there is more variability in how it can be utilized. While it is this variability that likely gives it its versatility, DRGS is not as straightforward to implement as cSCS. The purpose of this study was to assess the efficacy of DRGS on a broad number of diagnoses, determine which… Show more

Introduction Dorsal root ganglion stimulation (DRGS) is a powerful tool in the treatment of chronic, neuropathic pain. The premise of DRGS is similar to that of conventional spinal cord stimulation (cSCS), however, there is more variability in how it can be utilized. While it is this variability that likely gives it its versatility, DRGS is not as straightforward to implement as cSCS. The purpose of this study was to assess the efficacy of DRGS on a broad number of diagnoses, determine which dorsal root ganglia were associated with better outcomes for particular body parts/diagnoses, and evaluate what factors/parameters were associated with higher rates of trial success. Methods This is a physician initiated, multicenter retrospective registry of 217 patients trialed with DRGS. Data were collected via an online questionnaire that assessed specifics regarding the patient's pain, distribution, size, and response to treatment. The data were analyzed to see if there were certain diagnoses and/or parameters that were more or less associated with trial success. Results DRGS was found to be an effective treatment in all diagnoses evaluated within this study, most of which had statistically significant improvements in pain. The most important predictor of trial success was the amount of painful area covered by paresthesias during the programing phase. The number of leads utilized had a direct and indirect impact on trial success. Pain in the distribution of a specific peripheral nerve responded best and there was no statistical difference based on what body part was being treated. Conclusion DRGS can be an effective treatment for a variety of neuropathic pain syndromes, in addition to CRPS. It is recommended that a minimum of 2 leads should be utilized per area being treated. In addition, this therapy was shown to be equally efficacious in any body part/region so long as the area being treated is focal and not widespread. Show less

A comprehensive review on PRP concentration methods and published results.

Background and objectives: Osteoarthritis (OA) of the knee affects the aging population and has an associated influence on the health care system. Rigorous studies evaluating radiofrequency ablation for OA-related knee pain are lacking. This study compared long-term clinical safety and effectiveness of cooled radiofrequency ablation (CRFA) with intra-articular steroid (IAS) injection in managing OA-related knee pain.

Methods: This is a prospective, multicenter, randomized trial with 151… Show more

Background and objectives: Osteoarthritis (OA) of the knee affects the aging population and has an associated influence on the health care system. Rigorous studies evaluating radiofrequency ablation for OA-related knee pain are lacking. This study compared long-term clinical safety and effectiveness of cooled radiofrequency ablation (CRFA) with intra-articular steroid (IAS) injection in managing OA-related knee pain.

Methods: This is a prospective, multicenter, randomized trial with 151 subjects with chronic (≥6 months) knee pain that was unresponsive to conservative modalities. Knee pain (Numeric Rating Scale [NRS]), Oxford Knee Score, overall treatment effect (Global Perceived Effect), analgesic drug use, and adverse events were compared between CRFA and IAS cohorts at 1, 3, and 6 months after intervention.

Results: There were no differences in demographics between study groups. At 6 months, the CRFA group had more favorable outcomes in NRS: pain reduction 50% or greater: 74.1% versus 16.2%, P < 0.0001 (25.9% and 83.8% of these study cohorts, respectively, were nonresponders). Mean NRS score reduction was 4.9 ± 2.4 versus 1.3 ± 2.2, P < 0.0001; mean Oxford Knee Score was 35.7 ± 8.8 vs 22.4 ± 8.5, P < 0.0001; mean improved Global Perceived Effect was 91.4% vs 23.9%, P < 0.0001; and mean change in nonopioid medication use was CRFA > IAS (P = 0.02). There were no procedure-related serious adverse events.

Conclusions: This study demonstrates that CRFA is an effective long-term therapeutic option for managing pain and improving physical function and quality of life for patients with painful knee OA when compared with IAS injection. Show less

Chronic tendinopathy can be a painful and debilitating condition that can significantly impact a patient’s quality of life. Those who fail conservative management are traditionally left with open surgical tenotomy as the only treatment option. However, less invasive ultrasound-guided percutaneous interventions are gaining recognition as viable treatment modalities. Percutaneous Needle Tenotomy and the Tenex Health TX procedure are both safe and effective treatment options for patients with… Show more

Chronic tendinopathy can be a painful and debilitating condition that can significantly impact a patient’s quality of life. Those who fail conservative management are traditionally left with open surgical tenotomy as the only treatment option. However, less invasive ultrasound-guided percutaneous interventions are gaining recognition as viable treatment modalities. Percutaneous Needle Tenotomy and the Tenex Health TX procedure are both safe and effective treatment options for patients with chronic tendinopathy . This chapter discusses the indications, techniques, and therapeutic effects of these percutaneous interventions. Show less

OBJECT The  lateral  jack-­knife  position  is  often  used  during  transpsoas  surgery  to  improve  access  to  the  spine.  Postop-­ erative  neurological  signs  and  symptoms  are  very  common  after  such  procedures,  and  the  mechanism  is  not  adequately   understood.  The  objective  of  this  study  is  to  assess  if  the  lateral  jack-­knife  position  alone  can  cause  neurapraxia.  This   study  compares  neurological  status  at  baseline  and  after  positioning  in  the… Show more

OBJECT The  lateral  jack-­knife  position  is  often  used  during  transpsoas  surgery  to  improve  access  to  the  spine.  Postop-­ erative  neurological  signs  and  symptoms  are  very  common  after  such  procedures,  and  the  mechanism  is  not  adequately   understood.  The  objective  of  this  study  is  to  assess  if  the  lateral  jack-­knife  position  alone  can  cause  neurapraxia.  This   study  compares  neurological  status  at  baseline  and  after  positioning  in  the  25␣  right  lateral  jack-­knife  (RLJK)  and  the   right  lateral  decubitus  (RLD)  position.
METHODS Fifty  healthy  volunteers,  ages  21  to  35,  were  randomly  assigned  to  one  of  2  groups:  Group  A  (RLD)  and   Group  B  (RLJK).  Motor  and  sensory  testing  was  performed  prior  to  positioning.  Subjects  were  placed  in  the  RLD  or   RLJK  position,  according  to  group  assignment,  for  60  minutes.  Motor  testing  was  performed  immediately  after  this   60-­minute  period  and  again  60  minutes  thereafter.  Sensory  testing  was  performed  immediately  after  the  60-­minute  pe-­ riod  and  every  15  minutes  thereafter,  for  a  total  of  5  times.  Motor  testing  was  performed  by  a  physical  therapist  who  was   blinded  to  group  assignment.  A  follow-­up  call  was  made  7  days  after  the  positioning  sessions.

CONCLUSIONS
Twenty-five degrees of right lateral jack-knife positioning for 60 minutes results in neuropraxia of the nondependent lower extremity. Our  results  support  the  hypothesis  that  jack-­knife  positioning  alone  can  cause  postoperative  neurological  symptoms.

http://thejns.org/doi/abs/10.3171/2015.3.SPINE14928 KEY WORDS neurapraxia;;  jack-­knife;;  positioning  complications;;  technique Show less

This chapter focuses on the "evidence based indications" and proper execution of each type of procedure used to trat pain derived from a spinal origin.

The lateral transpsoas minimally invasive surgical (MIS) approach for interbody fusion poses risks to neural structures of the lumbar plexus as they course through the psoas. In addition to the potential neural risk, access to the L4-5 disc is difficult due to overlap of the iliac crest and L5-S1 access has not been a viable option from this approach. The minimally invasive oblique retroperitoneal surgical approach to the lumbar spine for interbody fusions is a newly described approach that… Show more

The lateral transpsoas minimally invasive surgical (MIS) approach for interbody fusion poses risks to neural structures of the lumbar plexus as they course through the psoas. In addition to the potential neural risk, access to the L4-5 disc is difficult due to overlap of the iliac crest and L5-S1 access has not been a viable option from this approach. The minimally invasive oblique retroperitoneal surgical approach to the lumbar spine for interbody fusions is a newly described approach that hopes to avoid disruption of the psoas and lower the risk of lumbar plexus injuries. This oblique approach offers access to the L2-S1 disc without the need to reposition the patient. Show less

The oblique corridor allows access to the L2–S1 discs while keeping the patient in a lateral decubitus position without a break in the table. Minimal psoas retraction without significant tendon disruption allowed for a generous corridor to the disc space. The L5–S1 disc space can be accessed from an oblique angle consistently with gentle retraction of the iliac vessels. This study supports the potential of an MIS oblique retroperitoneal approach to the L2–S1 discs.

The Epiducer lead delivery system is a novel lead delivery device that can be used to percutaneously implant S-Series paddle leads (St. Jude Medical, Plano, TX, USA) as well as multiple percutaneous leads obviating the need for laminectomy and/or multiple needle sticks, respectively. This study evaluates the safety and usage of the Epiducer lead delivery system.

Objectives. To assess if HA coated titanium pedicle screws exhibit the same electroconductive characteristics as non-coated screws.
Summary of Background Data. Stimulus evoked electromyographic testing has become a common tool for assisting in the confirmation of proper placement of pedicle screws during spine surgery. HA coated screws have recently come to market as a means of increasing “pullout” strength. The manufacturer has recommended that HA coated screws not be stimulated due to… Show more

Objectives. To assess if HA coated titanium pedicle screws exhibit the same electroconductive characteristics as non-coated screws.
Summary of Background Data. Stimulus evoked electromyographic testing has become a common tool for assisting in the confirmation of proper placement of pedicle screws during spine surgery. HA coated screws have recently come to market as a means of increasing “pullout” strength. The manufacturer has recommended that HA coated screws not be stimulated due to inconsistent stimulation thresholds. There is no published data to confirm this recommendation.
Methods. Resistance measurements were obtained from a random sampling of ten HA coated pedicle screws and ten non-coated screws. All screws were the same diameter (6.5mm) and length (45mm). Resistance measurements were taken from the Hexagonal Head slot through the shank of the screw to simulate surgical conditions, as well as at each thread. Surface Resistivity measurements were also taken for each screw, to determine voltage drop over its entire length.
Results. The non-Hydroxyapatite coated screws tested showed low resistive properties and proved to be an ideal conductor of electrical current. The resistive properties associated with the HA coated pedicle screws were found to be similar to those of commonly used insulators removing the effectiveness of evoked electromyographic responses.
Conclusion. Based on test results, this data suggest that the increased resistance value of the HA coated screw is large enough to prevent modern IOM equipment from delivering the necessary current through the shank of the screw to create an electromyographic responses safely. Any response that would be produced would be due to shunting of electric current from the non-coated head of the screw in to adjacent tissue and not through the shank of the screw. These study results suggest that HA coated screws should not be stimulated to assist in determining the accuracy of pedicle screw placement. Show less

This chapter reviews the lumbar plexus anatomy and proper methods for Intraoperative Neuromonitoring during Transpsoas Lumbar Surgery (XLIF, DLIF, LLIF)

A spinal cord stimulator (SCS) trial often involves the percutaneous placement of trial leads in the epidural space and has been used to treat a variety of chronic pain conditions, including complex regional pain syndrome I and II, failed back surgery syndrome, radiculopathy, postherpetic neuralgia, ischemic chest and limb pain, spinal cord injury, and phantom limb pain 1 and 2. Spinal epidural lipomatosis (SEL) is seldom considered a contraindication for an SCS trial. In this Clinical Pearl… Show more

A spinal cord stimulator (SCS) trial often involves the percutaneous placement of trial leads in the epidural space and has been used to treat a variety of chronic pain conditions, including complex regional pain syndrome I and II, failed back surgery syndrome, radiculopathy, postherpetic neuralgia, ischemic chest and limb pain, spinal cord injury, and phantom limb pain 1 and 2. Spinal epidural lipomatosis (SEL) is seldom considered a contraindication for an SCS trial. In this Clinical Pearl, we present the case of a patient who did not respond to a percutaneous SCS trial and who had abnormally high impedance levels at a spinal level that directly correlated with the presence of a large area of thoracic SEL, which was discovered on subsequent thoracic magnetic resonance imaging (MRI). Show less

An L4 neurogram will provide an accurate trajectory of L4 root/femoral nerve as it crosses the L4-5 intervertebral disc space. An accurate assessment is essential to help minimize the increasing frequency of thigh pain, parasthesias and weakness associated with the lateral access to the L4-5 intervertebral disc space. Femoral nerves that fall within Zones 2 and 3 will require more manipulation during retraction and may be better suited with a different surgical approach.

Surgical exposure of the lumbar intervertebral disc space with use of minimally invasive techniques via a transpsoas lateral approach has been developed and advocated. The approach has been reported to be suitable for anterior spinal arthrodesis procedures involving the disc spaces cephalad to L5 – S1. Advocates of the transpsoas lateral approach have described its potential benefits when compared with traditional anterior exposures, including less postoperative pain and reduced manipulation of… Show more

Surgical exposure of the lumbar intervertebral disc space with use of minimally invasive techniques via a transpsoas lateral approach has been developed and advocated. The approach has been reported to be suitable for anterior spinal arthrodesis procedures involving the disc spaces cephalad to L5 – S1. Advocates of the transpsoas lateral approach have described its potential benefits when compared with traditional anterior exposures, including less postoperative pain and reduced manipulation of the aorta and inferior vena cava. A variety of specialized retractor systems utilizing this approach have been developed to allow surgeons access to the disc space in a minimally invasive fashion.

In a recent JBJS study, doctors Hyun W. Bae, MD, Timothy T. Davis, MD, et.al. describe the lumbar plexus anatomy relevant to the transpsoas lateral approach. As procedures utilizing the transpsoas lateral surgical approach are performed with increasing frequency, there has been renewed interest in this anatomy. The authors conclude the risk of traction or compression on the femoral nerve is high at the L4 – L5 disc space and surgeons must have a comprehensive understanding not only of the neural anatomy but also the effect of dilators and retractor blades on the neural structures. Show less

BACKGROUND:

The transpsoas lateral surgical approach has been advocated as an alternative to direct anterior approaches for less invasive or minimally invasive access to the spine. Postoperative thigh pain, paresthesia, and/or weakness have been described after the use of this surgical approach. The purpose of this cadaveric anatomic study is to provide a description of the lumbar plexus as it relates to the transpsoas lateral surgical approach.
METHODS:

Dissection of the… Show more

BACKGROUND:

The transpsoas lateral surgical approach has been advocated as an alternative to direct anterior approaches for less invasive or minimally invasive access to the spine. Postoperative thigh pain, paresthesia, and/or weakness have been described after the use of this surgical approach. The purpose of this cadaveric anatomic study is to provide a description of the lumbar plexus as it relates to the transpsoas lateral surgical approach.
METHODS:

Dissection of the lumbar plexus was performed in eighteen cadaveric specimens. Needle markers were placed in the L2-L3, L3-L4, and L4-L5 discs in the midcoronal plane. The anatomic structures were surveyed, and the proximity of the needle to the neural structures was observed.
RESULTS:

In thirteen of the eighteen specimens, the femoral nerve received its contributions from the L2 to L4 nerve roots and was formed at the L4-L5 disc space. In all specimens, the femoral nerve passed dorsal to or directly at the midpoint of the disc. In three specimens, the needle displaced or was immediately adjacent to the femoral nerve. The femoral nerve was found between the needle and the posterior aspect of the L4-L5 disc space in thirteen of the eighteen specimens.
CONCLUSIONS:

Because of the proximity of the neural elements, in particular the femoral nerve, to the center of the disc space, the transpsoas lateral surgical approach to the L4-L5 disc space will likely cause intraoperative displacement of neural structures from their anatomic course during retractor dilation. Careful attention should be paid to retractor placement and dilation time during transpsoas lateral access surgery, particularly at the L4-L5 disc. Show less

Because of the proximity of the neural elements, in particular the femoral nerve, to the center of the disc space, the transpsoas lateral surgical approach to the L4-L5 disc space will likely cause intraoperative displacement of neural structures from their anatomic course during retractor dilation. Careful attention should be paid to retractor placement and dilation time during transpsoas lateral access surgery, particularly at the L4-L5 disc

STUDY DESIGN:

Retrospective study with independent evaluation of patient outcomes approximately 1 year post-intradiscal electrothermal therapy (IDET). OBJECTIVE.: To assess functional status, symptoms, and subsequent treatments of patients treated with IDET.
SUMMARY OF BACKGROUND DATA:

IDET was introduced as a procedure for discogenic pain. Several studies reported improvement in >70% of patients.
METHODS:

Seventeen physicians referred 60 patients. Each patient had… Show more

STUDY DESIGN:

Retrospective study with independent evaluation of patient outcomes approximately 1 year post-intradiscal electrothermal therapy (IDET). OBJECTIVE.: To assess functional status, symptoms, and subsequent treatments of patients treated with IDET.
SUMMARY OF BACKGROUND DATA:

IDET was introduced as a procedure for discogenic pain. Several studies reported improvement in >70% of patients.
METHODS:

Seventeen physicians referred 60 patients. Each patient had a positive discogram and had been treated with IDET. Patients were contacted approximately 1 year post-IDET, answered a telephone interview, and completed a self-administered questionnaire. Overall patient satisfaction, pain, functional and work status, analgesic usage, and subsequent treatments were noted. Kaplan-Meier survival curve was generated to predict the percentage that would undergo lumbar surgery after IDET.
RESULTS:

Average age was 40 years (range 25-64 years) with 66% males and 34% females. Of the 44 patients who responded, 6 patients had a lumbar surgery within 1 year. Their outcomes were excluded from descriptive analysis; 97% continued to have back pain, 11 (29%) reported more pain post versus pre-IDET, 15 (39%) had less pain, and 11 (29%) reported no change; 11 (29%) reported using more pain medication post-IDET, 10 (26%) used the same, 12 (32%) used less, and 5 (13%) used none; 19 (50%) were dissatisfied with IDET, 14 (37%) were satisfied, and 5 (13%) were undecided; 20 (53%) would have the procedure again, 12 (31%) would not, and 6 (16%) were unsure. Most patients wore a brace >6 hours/day after surgery (duration 1-15 months). Sixteen (42%) were employed full-time pre-IDET and 11 (29%) were employed full-time post-IDET.
CONCLUSION:

At 1-year post-IDET, half of patients were dissatisfied with their outcome. The percentage of patients on disability remained constant. The estimated proportion of patients undergoing fusion was predicted to be 15% at 1 year and 30% at 2 years. Show less

In hopes of improving outcomes for patients with discogenic pain, less invasive techniques that reduce trauma and shorten the recovery period have been developed. This article attempts to present a comprehensive description of minimally invasive techniques, specifically heat treatments, for lumbar disc disease. The goal is to inform and educate the reader on the various thermal therapies available for lumbar disc disease by evaluating the scientific data in an objective manner.